PRAPARE is a standardized patient social risk assessment tool made up of a set of national core measures with a set of optional measures for community priorities. It was developed and informed through research, existing social risk assessments, and stakeholder engagement. The tool aligns with national SDOH initiatives, measures proposed under Meaningful Use, ICD-10 clinical coding, and health centers’ Uniform Data System (UDS). PRAPARE templates exist for select EHR such as eClinicalWorks, Epic, GE Centricity, and NextGen and free to the public. The core PRAPARE measures are:
The optional PRAPARE measures are:
PRAPARE helps health care providers who serve underserved populations toward more integrated care. Pilot teams in Hawaii, Iowa, New York, and Oregon showed the feasibility of collecting PRAPARE data in electronic health records (EHRs). The tool also did not take long to administer, and staff found it helpful in assessing and addressing patients’ needs. In addition, PRAPARE can be administered by a wide range of staff at various times in clinic workflow. Organizations are using the tool to develop interventions and partnerships and streamline care management programs.
In 2016, Health Leads launched a series of toolkits to guide clinicians and health system leaders to integrate social needs interventions into medical care. The screening toolkit is based on clinically-validated guidelines from the Institute of Medicine, Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality. The tool allows health systems and practices with information to customize their screening approach based on their unique scope, goals, and target population of their social needs programs. The toolkit offers essential social need domains as well as optional social need domains. Included in the essential domain are:
Depending on the goals of a health system and their initiative, optional categories may be included on a social determinants of health screening tool. The optional domains include:
The Health Leads Screening Toolkit also provides information and advice on how to develop and use a successful screening tool. Advice includes making the questionnaires and forms short and simple, choosing clinically validated questions at the right level of precision, integrating the screening tool into clinical workflows, asking patients to prioritize and make goals, and piloting before scaling to entire populations.
The American Academy of Family Physicians (AAFP) developed a Social Needs Screening tool to help providers quickly and effectively screen patients and link them to the necessary community resources when necessary. The tool was designed to be used by family physicians at any stage of practice and is intended to allow health care providers to customize the tool to their individual practice, population, and community needs. The tool advocates for team-based care when addressing SDOH where all team members have a role to play including receptionists/medical assistants, nurses, physicians, health educators, administrators and social workers or community health workers. The Social Needs Screening tool includes a short and long-form screening tool that can be adapted at the physician’s practice. The social needs included in the screening tool were chosen based on the quality of evidence that links poor health and increased health utilization to cost, social needs that can often be addressed by community services, and social needs not routinely addressed by health care providers. The short-form version screens for five key health-related social needs:
The long-form version is optional for practices that choose to screen for other needs. In addition to the five key health-related needs, the long-form can also screen for employment, education, child care, and financial strain. The screening tool was created so that it does not need to be administered by a physician in order that it does not interrupt the flow of the visit. Additionally, while the screening tool can be given through an in-person interview, it is advised to be self-administered so patients are more likely to disclose sensitive information, i.e. interpersonal violence. A community-level SDOH toolkit will be released in March to help determine if a practice is ready to start intervening after assessing their patient’s SDOH needs and how to assess community needs to inform practices on how to best deliver correct referral resources. The toolkit will also provide strategies for developing partnerships with community social and behavioral health resources to support screening and referral processes.
